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Biyun L, Yahui H, Yuanfang L, Xifeng G, Dao W. Risk factors for invasive fungal infections after haematopoietic stem cell transplantation: a systematic review and meta-analysis. Clin Microbiol Infect 2024; 30:601-610. [PMID: 38280518 DOI: 10.1016/j.cmi.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Invasive fungal infections (IFIs) are common infectious complications after haematopoietic stem cell transplantation (HSCT), seriously threatening the survival of patients. OBJECTIVES This systematic review aimed to investigate risk factors associated with IFIs following HSCT. METHODS Two authors independently conducted the selection of studies and extraction of data. Risk factors for IFIs, invasive aspergillosis or invasive mould infections and invasive candida infection after HSCT were compiled separately by meta-analysis using RevMan 5.4 and R language 4.1.2. DATA SOURCES Pubmed, EMBASE, Web of Science, and the Cochrane Library until April 2023. STUDY ELIGIBILITY CRITERIA Case-control or cohort studies that assessed risk factors for IFIs among HSCT recipients were included. PARTICIPANTS Patients experiencing HSCT. TEST/S None. REFERENCE STANDARD The IFIs were defined according to the European Organisation for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) criteria, or a similar definition. ASSESSMENT OF RISK OF BIAS A modified version of the Newcastle-Ottawa Scale was used. METHODS OF DATA SYNTHESIS A random-effects model with the Mantel-Haenszel method was used to pool results from primary studies. RESULTS Out of 1637 studies screened, 51 studies involving 109 155 patients were included, with 45 studies providing adequate data for meta-analysis. Identified risk factors for IFIs included prolonged neutropenia, intensified therapy for graft-versus-host disease (GVHD), previous transplantation, previous proven or probable IFI, acute GVHD ≥ grade II, extensive or severe chronic GVHD, use of anti-thymocyte globulin during transplantation, haploidentical transplantation, high-dose glucocorticoids, Epstein-Barr virus infection, cytomegalovirus infection or reactivation, and lower albumin. Conversely, antifungal prophylaxis emerged as the sole preventive factor. For invasive aspergillosis or invasive mould infections, the top risk factors were extensive or severe chronic GVHD, respiratory viral infection, high-dose glucocorticoids, acute GVHD ≥ grade II, and human leukocyte antigen mismatch. Cord blood transplantation was the sole significant risk factor for invasive candidiasis. However, there was likely a high degree of interdependence among various risk factors. DISCUSSION This meta-analysis provides a thorough review of risk factors for IFIs infection after HSCT. The achieved insights can aid in stratifying patients who are at an elevated risk of IFIs and promoting antifungal preventive strategies.
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Affiliation(s)
- Li Biyun
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Han Yahui
- Department of Pediatric Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Yuanfang
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guo Xifeng
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wang Dao
- Department of Pediatric Hematology and Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Shahid Z, Etra AM, Levine JE, Riches ML, Baluch A, Hill JA, Nakamura R, Toor AA, Ustun C, Young JAH, Perales MA, Epstein DJ, Murthy HS. Defining and Grading Infections in Clinical Trials Involving Hematopoietic Cell Transplantation: A Report From the BMT CTN Infectious Disease Technical Committee. Transplant Cell Ther 2024; 30:540.e1-540.e13. [PMID: 38458478 DOI: 10.1016/j.jtct.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/19/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
The Blood and Marrow Transplant Clinical Trials Network (BMT-CTN) was established in 2001 to conduct large multi-institutional clinical trials addressing important issues towards improving the outcomes of HCT and other cellular therapies. Trials conducted by the network investigating new advances in HCT and cellular therapy not only assess efficacy but require careful capturing and severity assessment of adverse events and toxicities. Adverse infectious events in cancer clinical trials are typically graded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE). However, there are limitations to this framework as it relates to HCT given the associated immunodeficiency and delayed immune reconstitution. The BMT-CTN Infection Grading System is a monitoring tool developed by the BMT CTN to capture and monitor infectious complications and differs from the CTCAE by its classification of infections based on their potential impact on morbidity and mortality for HCT recipients. Here we offer a report from the BMT CTN Infectious Disease Technical Committee regarding the rationale, development, and revising of BMT-CTN Infection Grading System and future directions as it applies to future clinical trials involving HCT and cellular therapy recipients.
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Affiliation(s)
- Zainab Shahid
- Department of Medicine, Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
| | - Aaron M Etra
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marcie L Riches
- Department of Medicine, Center for International Blood and Marrow Transplantation Research (CIBMTR), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aliyah Baluch
- Division of Infectious Diseases, Moffitt Cancer Center, Tampa, Florida
| | - Joshua A Hill
- Department of Medicine, University of Washington, WA and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Wisconsin
| | - Ryo Nakamura
- Division of Hematology and HCT, City of Hope, Duarte, California
| | - Amir A Toor
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Celalettin Ustun
- Division of Hematology, Oncology and Cell Therapy, Section of Bone Marrow Transplantation and Cellular Therapy, Rush Medical College, Chicago, Illinois
| | - Jo-Anne H Young
- Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis, Minnesota
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center; Weill Cornell Medical College, New York, New York
| | - David J Epstein
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
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Li X, Yang J, Cai Y, Huang C, Xu X, Qiu H, Niu J, Zhou K, Zhang Y, Xia X, Wei Y, Shen C, Tong Y, Dong B, Wan L, Song X. Low-dose anti-thymocyte globulin plus low-dose post-transplant cyclophosphamide-based regimen for prevention of graft-versus-host disease after haploidentical peripheral blood stem cell transplants: a large sample, long-term follow-up retrospective study. Front Immunol 2023; 14:1252879. [PMID: 37954615 PMCID: PMC10639171 DOI: 10.3389/fimmu.2023.1252879] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction The novel low-dose anti-thymocyte (ATG, 5 mg/kg) plus low-dose post-transplant cyclophosphamide (PTCy, 50 mg/kg) (low-dose ATG/PTCy)-based regimen had promising activity for prevention of graft-versus-host disease (GVHD) in haploidentical-peripheral blood stem cell transplantation (haplo-PBSCT), but its impacts on long-term outcomes remain to be defined. Methods We performed a large sample, long-term follow-up retrospective study to evaluate its efficacy for GVHD prophylaxis. Results The study enrolled 260 patients, including 162 with myeloid malignancies and 98 with lymphoid malignancies. The median follow-up time was 27.0 months. For the entire cohort, the cumulative incidences (CIs) of grade II-IV and III-IV acute GVHD (aGVHD) by 180 days were 13.46% (95% CI, 9.64%-17.92%) and 5.77% (95% CI, 3.37%-9.07%); while total and moderate/severe chronic GVHD (cGVHD) by 2 years were 30.97% (95% CI, 25.43%-36.66%) and 18.08% (95% CI, 13.68%-22.98%), respectively. The 2-year overall survival (OS), relapse-free survival (RFS), GVHD-free, relapse-free survival (GRFS), non-relapse mortality (NRM), and CIs of relapse were 60.7% (95% CI, 54.8%-67.10%), 58.1% (95% CI, 52.2%-64.5%), 50.6% (95% CI, 44.8-57.1%), 23.04% (95% CI, 18.06%-28.40%), and 18.09% (95% CI, 14.33%-23.97%, respectively. The 1-year CIs of cytomegalovirus (CMV) and Epstein-Barr virus (EBV) reactivation were 43.46% (95% CI, 37.39%-49.37%) and 18.08% (95% CI, 13.68%-22.98%), respectively. In multivariate analysis, the disease status at transplantation was associated with inferior survivor outcomes for all patients and myeloid and lymphoid malignancies, while cGVHD had superior outcomes for all patients and myeloid malignancies, but not for lymphoid malignancies. Discussion The results demonstrated that the novel regimen could effectively prevent the occurrence of aGVHD in haplo-PBSCT.
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Affiliation(s)
- Xingying Li
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Jun Yang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Yu Cai
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Chongmei Huang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Xiaowei Xu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Huiying Qiu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Jiahua Niu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Kun Zhou
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Ying Zhang
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Xinxin Xia
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Yu Wei
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Chang Shen
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Yin Tong
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Baoxia Dong
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Liping Wan
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
| | - Xianmin Song
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Engineering Technology Research Center of Cell Therapy and Clinical Translation, Shanghai Science and Technology Committee (STCSM), Shanghai, China
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van der Ploeg K, Sottile R, Kontopoulos T, Shaffer BC, Papanicolaou GA, Maloy MA, Cho C, Robinson KS, Perales MA, Le Luduec JB, Hsu KC. Emergence of human CMV-induced NKG2C+ NK cells is associated with CD8+ T-cell recovery after allogeneic HCT. Blood Adv 2023; 7:5784-5798. [PMID: 37196646 PMCID: PMC10561005 DOI: 10.1182/bloodadvances.2022008952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 05/19/2023] Open
Abstract
Cytomegalovirus (CMV) infection is associated with the expansion of a mature NKG2C+FcεR1γ- natural killer (NK) cell population. The exact mechanism underlying the emergence of NKG2C+ NK cells, however, remains unknown. Allogeneic hematopoietic cell transplantation (HCT) provides an opportunity to longitudinally study lymphocyte recovery in the setting of CMV reactivation, particularly in patients receiving T-cell-depleted (TCD) allografts. We analyzed peripheral blood lymphocytes from 119 patients at serial time points after infusion of their TCD allograft and compared immune recovery with that in samples obtained from recipients of T-cell-replete (T-replete) (n = 96) or double umbilical cord blood (DUCB) (n = 52) allografts. NKG2C+ NK cells were detected in 92% (45 of 49) of recipients of TCD HCT who experienced CMV reactivation. Although NKG2A+ cells were routinely identifiable early after HCT, NKG2C+ NK cells were identified only after T cells could be detected. T-cell reconstitution occurred at variable times after HCT among patients and predominantly comprised CD8+ T cells. In patients with CMV reactivation, recipients of TCD HCT expressed significantly higher frequencies of NKG2C+ and CD56neg NK cells compared with patients who received T-replete HCT or DUCB transplantation. NKG2C+ NK cells after TCD HCT were CD57+FcεR1γ+ and degranulated significantly more in response to target cells compared with the adaptive the NKG2C+CD57+FcεR1γ- NK cell population. We conclude that the presence of circulating T cells is associated with the expansion of a CMV-induced NKG2C+ NK cell population, a potentially novel example of developmental cooperation between lymphocyte populations in response to viral infection.
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Affiliation(s)
- Kattria van der Ploeg
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rosa Sottile
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Theodota Kontopoulos
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian C. Shaffer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Genovefa A. Papanicolaou
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Molly A. Maloy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christina Cho
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Kevin S. Robinson
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Adult BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Jean-Benoît Le Luduec
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katharine C. Hsu
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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5
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Little JS, Tandon M, Hong JS, Nadeem O, Sperling AS, Raje N, Munshi N, Frigault M, Barmettler S, Hammond SP. Respiratory infections predominate after day 100 following B-cell maturation antigen-directed CAR T-cell therapy. Blood Adv 2023; 7:5485-5495. [PMID: 37486599 PMCID: PMC10514400 DOI: 10.1182/bloodadvances.2023010524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023] Open
Abstract
Infections are an important complication after B-cell maturation antigen (BCMA)-directed chimeric antigen receptor (CAR) T-cell therapy and risks may differ between the early and late periods. We evaluated infections in 99 adults who received a first BCMA-directed CAR T-cell therapy (commercial and investigational autologous BCMA CAR T-cell products at the recommended phase 2 dose) for relapsed/refractory multiple myeloma between November 2016 and May 2022. Infections were recorded until day 365, if patients experienced symptoms with a microbiologic diagnosis, or for symptomatic site-specific infections treated with antimicrobials. One-year cumulative incidence functions were calculated based on time to first respiratory infection using dates of infection-free death and receipt of additional antineoplastic therapies as competing risks. Secondary analysis evaluated risk factors for late respiratory infections using univariate and multivariable Cox regression models. Thirty-seven patients (37%) experienced 64 infectious events over the first year after BCMA-directed CAR T-cell therapy, with 42 early infectious events (days, 0-100), and 22 late infectious events (days, 101-365). Respiratory infections were the most common site-specific infection and the relative proportion of respiratory infections increased in the late period (31% of early events vs 77% of late events). On multivariable analysis, hypogammaglobulinemia (hazard ratio [HR], 6.06; P = .044) and diagnosis of an early respiratory viral infection (HR, 2.95; P = .048) were independent risk factors for late respiratory infection. Respiratory infections predominate after BCMA CAR T-cell therapy, particularly after day 100. Hypogammaglobulinemia and diagnosis of an early respiratory infection are risk factors for late respiratory infections that may be used to guide targeted preventive strategies.
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Affiliation(s)
- Jessica S. Little
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
| | - Megha Tandon
- Harvard Medical School, Boston, MA
- Division of Allergy and Immunology, Massachusetts General Hospital, Boston, MA
| | - Joseph Seungpyo Hong
- Harvard Medical School, Boston, MA
- Division of Allergy and Immunology, Massachusetts General Hospital, Boston, MA
| | - Omar Nadeem
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Adam S. Sperling
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women’s Hospital, Boston, MA
| | - Noopur Raje
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Nikhil Munshi
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | - Matthew Frigault
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Sara Barmettler
- Harvard Medical School, Boston, MA
- Division of Allergy and Immunology, Massachusetts General Hospital, Boston, MA
| | - Sarah P. Hammond
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Massachusetts General Hospital Cancer Center, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
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Epstein DJ, Liang EC, Sharifi H, Lai YK, Arai S, Graber-Naidich A, Sundaram V, Nelson J, Hsu JL. Epidemiology of Lower Respiratory Tract Infections and Community-Acquired Respiratory Viruses in Patients with Bronchiolitis Obliterans Syndrome after Hematopoietic Cell Transplantation: A Retrospective Cohort Study. Transplant Cell Ther 2022; 28:705.e1-705.e10. [PMID: 35872303 PMCID: PMC9547900 DOI: 10.1016/j.jtct.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/05/2022] [Accepted: 07/15/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS)-chronic graft-versus-host disease (cGVHD) affecting the lungs-is an uncommon complication of allogeneic hematopoietic cell transplant (HCT). The epidemiology and complications of lower respiratory tract infections (LRTIs) and community-acquired respiratory viruses (CARVs) in these patients are poorly understood. OBJECTIVES We aim to characterize the epidemiology of LRTIs in patients with BOS complicating HCT. We also aim to explore the association of LRTIs and CARV detection on lung function in BOS patients. STUDY DESIGN Adult patients with BOS at Stanford Health Care between January 2010 and December 2019 were included in this retrospective cohort study. LRTI diagnosis was based on combined clinical, microbiologic, and radiographic criteria, using consensus criteria where available. RESULTS Fifty-five patients with BOS were included. BOS was diagnosed at a median of 19.2 (IQR 12.5-24.7) months after HCT, and patients were followed for a median of 29.3 (IQR 9.9-53.2) months from BOS diagnosis. Twenty-two (40%) patients died after BOS diagnosis; 17 patients died from complications of cGVHD (including respiratory failure and infection) and 5 died from relapsed disease. Thirty-four (61.8%) patients developed at least one LRTI. Viral LRTIs were most common, occurring in 29 (52.7%) patients, primarily due to rhinovirus. Bacterial LRTIs-excluding Nocardia and non-tuberculous mycobacteria (NTM)-were the second most common, occurring in 21 (38.2%) patients, mostly due to Pseudomonas aeruginosa. Fungal LRTIs, NTM, and nocardiosis occurred in 14 (25.5%), 10 (18.2%), and 4 (7.3%) patients, respectively. Median time to development of the first LRTI after BOS diagnosis was 15.3 (4.7-44.7) months. Twenty-six (76.5%) of the 34 patients who developed LRTIs had infections due to more than one type of organism-fungi, viruses, Nocardia, NTM, and other bacteria-over the observation period. Patients with at least one LRTI had significantly lower forced expiratory volume in one second percent predicted (FEV1%) (37% vs. 53%, p = 0.0096) and diffusing capacity of carbon monoxide (DLCO) (45.5% predicted vs. 69% predicted, p = 0.0001). Patients with at least one LRTI trended toward lower overall survival (OS) (p = 0.0899) and higher non-relapse mortality (NRM) (p = 0.2707). Patients with a CARV detected or LRTI diagnosed after BOS-compared to those without any CARV detected or LRTI diagnosed-were more likely to have a sustained drop in FEV1% from baseline of at least 10% (21 [61.8%] versus 7 [33.3%]) and a sustained drop in FEV1% of at least 30% (12 [36.4%] versus 2 [9.5%]). CONCLUSIONS LRTIs are common in BOS and associated with lower FEV1%, lower DLCO, and a trend toward decreased OS and higher NRM. Patients with LRTIs or CARVs (even absent lower respiratory tract involvement) were more likely to have substantial declines in FEV1% over time than those without. The array of organisms-including P. aeruginosa, mold, Nocardia, NTM, and CARVs-seen in BOS reflects the unique pathophysiology of this form of cGVHD, involving both systemic immunodeficiency and structural lung disease. These patterns of LRTIs and their outcomes can be used to guide clinical decisions and inform future research.
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Affiliation(s)
- David J Epstein
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | - Emily C Liang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Husham Sharifi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yu Kuang Lai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sally Arai
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Anna Graber-Naidich
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Vandana Sundaram
- Department of Medicine, Stanford University School of Medicine, Stanford, California; Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California; Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Joanna Nelson
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Joe L Hsu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
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7
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Young JAH, Jurdi NE, Rayes A, MacMillan ML, Holtan SG, Cao Q, Witte J, Arora M, Weisdorf DJ. Steroid sensitive acute GVHD, but not steroid dependent or steroid resistant, results in similar infection risk as no GVHD following allogeneic hematopoietic cell transplantation. Transplant Cell Ther 2022; 28:509.e1-509.e11. [PMID: 35577324 DOI: 10.1016/j.jtct.2022.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/25/2022] [Accepted: 05/05/2022] [Indexed: 11/15/2022]
Abstract
Patients with acute GVHD (aGVHD) have an increased risk for infectious complications after allogeneic hematopoietic cell transplantation (HCT), but the risk according to response to therapy is not well studied. We performed a retrospective analysis of the infectious complications for 1 year following allogeneic HCT at the University of Minnesota for 1143 pediatric and adult patients with and without aGVHD. Patients with aGVHD were classified into treatment response groups based on response to corticosteroids as first-line therapy: steroid sensitive (SS, n=114), steroid resistant (SR, n=103) and steroid dependent (SD, n=168) aGVHD. We observed that the cumulative incidence and density of infections for patients with SS aGVHD parallels those having no GVHD. Infection density (the number of infections that occurred per 100 days at risk) was greater for aGVHD than patients with no GVHD over both early and later post-transplant periods. For GVHD patients, among the infections developed from onset of aGVHD through 80 days of treatment, and until 1-year following transplantation, SS and SD patients had fewer bacterial and viral infections than SR patients. The overlap of non-relapse mortality between SS and SD GVHD patients is a function of SD GVHD being responsive to steroid therapy, even if continued therapy is required. In summary, while valid goals may include reducing unneeded antibacterial antibiotic therapy and preserving microbiome diversity, these data suggest that anti-infective therapy is justified by the density of infections observed during active GVHD treatment.
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Affiliation(s)
| | - Najla El Jurdi
- Blood and Marrow Transplantation Program, University of Minnesota
| | - Ahmad Rayes
- Blood and Marrow Transplantation Program, University of Minnesota; Department of Pediatrics, University of Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplantation Program, University of Minnesota; Department of Pediatrics, University of Minnesota
| | - Shernan G Holtan
- Blood and Marrow Transplantation Program, University of Minnesota
| | - Qing Cao
- Biostatistics and Informatics, Clinical and Translational Science Institute, University of Minnesota
| | - Judy Witte
- Blood and Marrow Transplantation Program, University of Minnesota
| | - Mukta Arora
- Blood and Marrow Transplantation Program, University of Minnesota
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8
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Affiliation(s)
- George R Thompson
- From the Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis, Sacramento (G.R.T.); and the Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis (J.-A.H.Y.)
| | - Jo-Anne H Young
- From the Department of Medicine, Division of Infectious Diseases, and the Department of Medical Microbiology and Immunology, University of California, Davis, Sacramento (G.R.T.); and the Department of Medicine, Division of Infectious Disease and International Medicine, Program in Adult Transplant Infectious Disease, University of Minnesota, Minneapolis (J.-A.H.Y.)
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9
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Infectious complications in relapsed refractory multiple myeloma patients after BCMA Car t-cell therapy. Blood Adv 2021; 6:2045-2054. [PMID: 34543400 PMCID: PMC9006279 DOI: 10.1182/bloodadvances.2020004079] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 07/05/2021] [Indexed: 11/20/2022] Open
Abstract
B-cell maturation antigen-targeted chimeric antigen receptor T cell therapy (BCMA CAR-T) is an effective treatment for relapsed refractory multiple myeloma (RRMM). However the pattern of infectious complications is not well-elucidated. We performed a single-center retrospective analysis of infection outcomes up to 1-year post BCMA CAR-T for MM from 2018-2020. Fifty-five MM patients were treated with BCMA CAR-T. Prior to lymphodepletion (LD), 35% of patients had severe hypogammaglobulinemia and 18% had severe lymphopenia. Most patients (68%) received bridging chemotherapy (BC) prior to LD. In the first month post CAR-T, 98% patients had grade 3-4 neutropenia. At 1-year post infusion, 76% patients had hypogammaglobulinemia. With a median follow-up of 6.0 months (95% CI: 4.7 to 7.4), there were a total of 47 infection events in 29 (53%) patients, 40% bacterial, 53% viral and 6% fungal. Most (92%) were mild-moderate and of the lower/upper respiratory tract system (68%). Half of infections (53%) occurred in the first 100 days post CAR-T infusion. Though no statistically significant risk factors for infection were identified, prior lines of therapy, use of BC, recent infections, and post CAR-T lymphopenia were identified as possible risk factors that need to be further explored. This is the largest study to date to assess the infectious complications post BCMA CAR-T. Despite multiple risk factors for severe immunosuppression in this cohort, relatively few life-threatening or severe infections occurred. Further larger studies are needed to better characterize the risk factors for and occurrence of infections post BCMA CAR-T.
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10
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Oncolytic virotherapy in hematopoietic stem cell transplantation. Hum Immunol 2021; 82:640-648. [PMID: 34119352 DOI: 10.1016/j.humimm.2021.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/29/2021] [Accepted: 05/29/2021] [Indexed: 12/28/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative option for various hematologic malignancies. However, fatal complications, such as relapse and graft-versus-host disease (GVHD) hampered favorable HSCT outcomes. Cancer cells remained in the body following the conditioning regimen, or those contaminating the autologous graft can cause relapse. Although the relapse is much lesser in allogeneic HSCT, GVHD is still a life-threatening complication in this type of HSCT. Researchers are seeking various strategies to reduce relapse and GVHD in HSCT with minimum effects on the engraftment and immune-reconstitution. Oncolytic viruses (OVs) are emerging anti-cancer agents with promising results in battling solid tumors. OVs can selectively replicate in the malignant cells in which the antiviral immune responses have defected. Hence, they could be used as a purging agent to eradicate the tumoral contamination of autologous grafts with no damages to hematopoietic stem cells. Moreover, they have been shown to alleviate GVHD complications through modulating alloreactive T cell responses. Primary results promise using OVs as a strategy to reduce both relapse and GVHD in the HSCT without affecting hematologic and immunologic engraftment. Herein, we provide the latest findings in the field of OV therapy in HSCT and discuss their pros and cons.
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11
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Immune reconstitution and infectious complications following axicabtagene ciloleucel therapy for large B-cell lymphoma. Blood Adv 2021; 5:143-155. [PMID: 33570626 DOI: 10.1182/bloodadvances.2020002732] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy targeting CD19 has significantly improved outcomes in the treatment of refractory or relapsed large B-cell lymphoma (LBCL). We evaluated the long-term course of hematologic recovery, immune reconstitution, and infectious complications in 41 patients with LBCL treated with axicabtagene ciloleucel (axi-cel) at a single center. Grade 3+ cytopenias occurred in 97.6% of patients within the first 28 days postinfusion, with most resolved by 6 months. Overall, 63.4% of patients received a red blood cell transfusion, 34.1% of patients received a platelet transfusion, 36.6% of patients received IV immunoglobulin, and 51.2% of patients received growth factor (granulocyte colony-stimulating factor) injections beyond the first 28 days postinfusion. Only 40% of patients had recovered detectable CD19+ B cells by 1 year, and 50% of patients had a CD4+ T-cell count <200 cells per μL by 18 months postinfusion. Patients with durable responses to axi-cel had significantly longer durations of B-cell aplasia, and this duration correlated strongly with the recovery of CD4+ T-cell counts. There were significantly more infections within the first 28 days compared with any other period of follow-up, with the majority being mild-moderate in severity. Receipt of corticosteroids was the only factor that predicted risk of infection in a multivariate analysis (hazard ratio, 3.69; 95% confidence interval, 1.18-16.5). Opportunistic infections due to Pneumocystis jirovecii and varicella-zoster virus occurred up to 18 months postinfusion in patients who prematurely discontinued prophylaxis. These results support the use of comprehensive supportive care, including long-term monitoring and antimicrobial prophylaxis, beyond 12 months after axi-cel treatment.
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12
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The impact of graft cell source on bloodstream infection in the first 100 days after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2021; 56:1625-1634. [PMID: 33608659 DOI: 10.1038/s41409-021-01229-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 01/06/2021] [Accepted: 01/26/2021] [Indexed: 12/22/2022]
Abstract
Bloodstream infection (BSI) is a major infectious complication after allogeneic hematopoietic cell transplantation (HCT). To clarify the impact of graft cell source on the incidence of BSI after transplantation, we retrospectively examined 782 adult patients receiving their first allogeneic HCT: 122 recipients of related peripheral blood stem cells or bone marrow, 215 recipients of unrelated bone marrow, and 445 recipients of unrelated umbilical cord blood (U-CB). The cumulative incidence of BSI was 42.5% at 100 days after transplantation (95% confidence interval, 39.0-46.0). Gram-positive cocci were present in 64.2% of detected isolates. Among the pre-transplant factors including age, performance status, primary disease, disease status, graft cell source, sex and ABO blood type matching, and the intensity of conditioning regimen, U-CB use was identified as the most significant risk factor for BSI by multivariate analysis (hazard ratio, 1.76; 95% confidence interval, 1.40-2.22; p < 0.00001). Among the U-CB recipients, those who are not in remission at the time of transplantation were at the greatest risk of BSI (hazard ratio, 1.69; 95% confidence interval, 1.14-2.50; p < 0.01). The study makes it clear that graft cell source has an impact on BSI development after allogeneic HCT.
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13
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Bremm M, Krastel T, Cappel C, Zimmermann O, Pfeffermann LM, Katzki V, Bonig H, Schäfer R, Rettinger E, Merker M, Bremm S, Schaefer K, Klingebiel T, Soerensen J, Bader P, Huenecke S. Depletion of CD45RA + T cells: Advantages and disadvantages of different purification methods. J Immunol Methods 2021; 492:112960. [PMID: 33417916 DOI: 10.1016/j.jim.2021.112960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 12/03/2020] [Accepted: 12/31/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recently, new advances were made regarding the depletion of CD45RA+ naïve T cells from haploidentical grafts as they are suspected to be the most alloreactive. METHODS Within this project we investigated CD45RA-depletion from G-CSF mobilized PBSC by two different purification strategies according to GMP, specifically direct depletion of CD45RA+ cells (one-step approach), or CD34-positive selection followed by CD45RA-depletion (two-step approach). RESULTS With log -3.9 and - 3.8 the depletion quality of CD45RA+ T cells was equally for both approaches together with a close to complete CD19+ B cell depletion. However, due to a high expression of CD45RA the majority of NK cells were lost within both CD45RA depletion strategies. Stem cell recovery after one-step CD45RA-depletion was at median 52.0% (range: 49.7-67.2%), which was comparable to previously published recovery data received from direct CD34 positive selection. Memory T cell recovery including CD4+ and CD8+ memory T cell subsets was statistically not differing between both purification approaches. The recovery of CD4+ and CD8+ T cells was as well similar, but overall a higher amount of cytotoxic than T-helper cells were lost as indicated by an increase of the CD4/CD8 ratio. CONCLUSIONS CD45RA-depletion from G-CSF mobilized PBSC is feasible as one- and two-step approach and results in sufficient reduction of CD45RA+ T cells as well as B cells, but also to a co-depletion of NK cells. However, by gaining two independent cell products, the two-step approach enables the highest clinical flexibility in regard to individual graft composition with precise dosage of stem cells and T cells.
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Affiliation(s)
- Melanie Bremm
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany.
| | - Theresa Krastel
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Claudia Cappel
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Olga Zimmermann
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Lisa-Marie Pfeffermann
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Verena Katzki
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology, Goethe-University Frankfurt/Main, German Red Cross Blood Donor Service Baden-Württemberg-Hessen, Frankfurt/Main, Germany
| | - Richard Schäfer
- Institute for Transfusion Medicine and Immunohematology, Goethe-University Frankfurt/Main, German Red Cross Blood Donor Service Baden-Württemberg-Hessen, Frankfurt/Main, Germany
| | - Eva Rettinger
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Michael Merker
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Sebastian Bremm
- Data Analytics & Visualization, Frankfurt University of Applied Sciences, Frankfurt/Main, Germany
| | - Kirsten Schaefer
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Thomas Klingebiel
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Jan Soerensen
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Peter Bader
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
| | - Sabine Huenecke
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt/Main, Germany
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14
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Ferdjallah A, Young JAH, MacMillan ML. A Review of Infections After Hematopoietic Cell Transplantation Requiring PICU Care: Transplant Timeline Is Key. Front Pediatr 2021; 9:634449. [PMID: 34386464 PMCID: PMC8353083 DOI: 10.3389/fped.2021.634449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 07/01/2021] [Indexed: 12/16/2022] Open
Abstract
Despite major advances in antimicrobial prophylaxis and therapy, opportunistic infections remain a major cause of morbidity and mortality after pediatric hematopoietic cell transplant (HCT). Risk factors associated with the development of opportunistic infections include the patient's underlying disease, previous infection history, co-morbidities, source of the donor graft, preparative therapy prior to the graft infusion, immunosuppressive agents, early and late toxicities after transplant, and graft-vs.-host disease (GVHD). Additionally, the risk for and type of infection changes throughout the HCT course and is greatly influenced by the degree and duration of immunosuppression of the HCT recipient. Hematopoietic cell transplant recipients are at high risk for rapid clinical decompensation from infections. The pediatric intensivist must remain abreast of the status of the timeline from HCT to understand the risk for different infections. This review will serve to highlight the infection risks over the year-long course of the HCT process and to provide key clinical considerations for the pediatric intensivist by presenting a series of hypothetical HCT cases.
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Affiliation(s)
- Asmaa Ferdjallah
- Department of Pediatrics, Division of Blood and Marrow Transplantation and Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Jo-Anne H Young
- Department of Medicine, Division of Infectious Disease and International Medicine, Program in Transplant Infectious Disease, University of Minnesota, Minneapolis, MN, United States
| | - Margaret L MacMillan
- Department of Pediatrics, Division of Blood and Marrow Transplantation and Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
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15
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Comparative efficacy of 20 graft-versus-host disease prophylaxis therapies for patients after hematopoietic stem-cell transplantation: A multiple-treatments network meta-analysis. Crit Rev Oncol Hematol 2020; 150:102944. [DOI: 10.1016/j.critrevonc.2020.102944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/08/2020] [Accepted: 03/19/2020] [Indexed: 12/12/2022] Open
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16
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Sharpley FA, De-Silva D, Mahmood S, Sachchithanantham S, Ramsay I, Garcia Mingo A, Worthington S, Hughes D, Mehta A, Kyriakou C, Griffiths PD, Wechalekar AD. Cytomegalovirus reactivation after bortezomib treatment for multiple myeloma and light chain amyloidosis. Eur J Haematol 2020; 104:230-235. [PMID: 31815313 DOI: 10.1111/ejh.13366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Cytomegalovirus (CMV) is an opportunistic herpesvirus, and reactivation of infection is possible in immunocompromised patients. Historically, the risk for haematology patients is restricted to those treated with an allogeneic transplant or T-cell depleting agents. Bortezomib is a highly efficacious proteasome inhibitor widely used to treat multiple myeloma and light chain (AL) amyloidosis patients. The objective of this small prospective study was to quantify the risk of CMV reactivation associated with bortezomib treatment. METHODS Fifty-seven consecutive multiple myeloma or AL amyloidosis patients commencing bortezomib-based therapy were included. Viral copy numbers were established at baseline and then at fortnightly intervals during treatment. Pre-emptive anti-viral treatment was initiated in patients with a viral load >7500 copies/mL. RESULTS Reactivation of CMV was detected in 39% (n = 12/31) of seropositive bortezomib treated patients compared with 0% of CMV seronegative patients. Detectable DNAemia developed during the first two cycles of treatment in 83% (n = 10/12) patients. Anti-viral treatment was initiated in 42% (n = 5/12), but no cases of active CMV disease were seen. CONCLUSION This study suggests that there is a substantial risk of CMV reactivation in CMV-seropositive plasma cell dyscrasia patients treated with bortezomib.
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Affiliation(s)
- Faye A Sharpley
- National Amyloidosis Centre, University College London, London, UK
| | - Dunnya De-Silva
- Department of Haematology, University College London Hospitals, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London, London, UK.,Department of Haematology, University College London Hospitals, London, UK.,Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, University College London, London, UK.,Department of Haematology, University College London Hospitals, London, UK.,Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Isobel Ramsay
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Ana Garcia Mingo
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Sarah Worthington
- Department of Haematology, University College London Hospitals, London, UK
| | - Derralynn Hughes
- Department of Haematology, Royal Free London NHS Foundation Trust, London, UK
| | - Atul Mehta
- Department of Haematology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Paul D Griffiths
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London, London, UK.,Department of Haematology, University College London Hospitals, London, UK.,Department of Virology, Royal Free London NHS Foundation Trust, London, UK
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17
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Summers C, Sheth VS, Bleakley M. Minor Histocompatibility Antigen-Specific T Cells. Front Pediatr 2020; 8:284. [PMID: 32582592 PMCID: PMC7283489 DOI: 10.3389/fped.2020.00284] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/06/2020] [Indexed: 01/05/2023] Open
Abstract
Minor Histocompatibility (H) antigens are major histocompatibility complex (MHC)/Human Leukocyte Antigen (HLA)-bound peptides that differ between allogeneic hematopoietic stem cell transplantation (HCT) recipients and their donors as a result of genetic polymorphisms. Some minor H antigens can be used as therapeutic T cell targets to augment the graft-vs.-leukemia (GVL) effect in order to prevent or manage leukemia relapse after HCT. Graft engineering and post-HCT immunotherapies are being developed to optimize delivery of T cells specific for selected minor H antigens. These strategies have the potential to reduce relapse risk and thereby permit implementation of HCT approaches that are associated with less toxicity and fewer late effects, which is particularly important in the growing and developing pediatric patient. Most minor H antigens are expressed ubiquitously, including on epithelial tissues, and can be recognized by donor T cells following HCT, leading to graft-vs.-host disease (GVHD) as well as GVL. However, those minor H antigens that are expressed predominantly on hematopoietic cells can be targeted for selective GVL. Once full donor hematopoietic chimerism is achieved after HCT, hematopoietic-restricted minor H antigens are present only on residual recipient malignant hematopoietic cells, and these minor H antigens serve as tumor-specific antigens for donor T cells. Minor H antigen-specific T cells that are delivered as part of the donor hematopoietic stem cell graft at the time of HCT contribute to relapse prevention. However, in some cases the minor H antigen-specific T cells delivered with the graft may be quantitatively insufficient or become functionally impaired over time, leading to leukemia relapse. Following HCT, adoptive T cell immunotherapy can be used to treat or prevent relapse by delivering large numbers of donor T cells targeting hematopoietic-restricted minor H antigens. In this review, we discuss minor H antigens as T cell targets for augmenting the GVL effect in engineered HCT grafts and for post-HCT immunotherapy. We will highlight the importance of these developments for pediatric HCT.
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Affiliation(s)
- Corinne Summers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Vipul S Sheth
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Marie Bleakley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
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18
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A phase I dose finding study of intravenous voriconazole in pediatric patients undergoing hematopoietic cell transplantation. Bone Marrow Transplant 2019; 55:955-964. [PMID: 31768008 DOI: 10.1038/s41409-019-0757-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 11/08/2022]
Abstract
To optimize voriconazole dosing in pediatric hematopoietic cell transplantation (HCT), we conducted a phase I study with a modified 3 + 3 dose-escalation followed by an expansion cohort at the maximum tolerated, minimum efficacious dose (MTD/MED). Patients ≤21 years who required voriconazole for prevention or treatment of an invasive fungal infection were assigned to three age groups. Of the 59 evaluable patients, 13 were <2 years, 23 were 2-11, and 23 were 12-21. Therapeutic serum voriconazole troughs (1.5-5 µg/mL) drawn at 7 days after initiation determined efficacy. The MTD/MED was 12 mg/kg/dose q12 h × 2 loading doses, then 10 mg/kg/dose q12 h in patients <2, and was 10 mg/kg/dose q12 h in patients 2-11. The 12-21 age group had no dose-limiting toxicity at 8 mg/kg/dose q12 h; however, the MED was not reached. Drug-related AEs ≥grade 3 included increased bilirubin, transaminases, and creatinine, all occurring in <10%. There was no significant association between supra-therapeutic troughs and AEs. Five of 17 patients who had supra-therapeutic troughs (29%) had an AE, compared to 8 of 42 who did not (19%, p = 0.38). Observational population pharmacokinetic analysis demonstrated that inter-individual variability on voriconazole clearance was >100% CV, and clearance increased with age.
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19
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Luo H, Wang N, Huang L, Zhou X, Jin J, Li C, Wang D, Xu B, Xu J, Jiang L, Wang J, Cao Y, Xiao Y, Zhang Q, Mao X, Liu S, Chen L, Xiao M, Zhou J. Inflammatory signatures for quick diagnosis of life-threatening infection during the CAR T-cell therapy. J Immunother Cancer 2019; 7:271. [PMID: 31640816 PMCID: PMC6806557 DOI: 10.1186/s40425-019-0767-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 10/02/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor-modified (CAR) T-cell immunotherapy is a novel promising therapy for treatment of B-cell malignancy. Cytokine release syndrome (CRS) and infection are the most common adverse events during CAR T-cell therapy. Similar clinical presentation of concurrent CRS and infection makes it difficult to differentially diagnose and timely treat the condition. METHODS We analyzed the features of infection events during the first 30 days after CAR T-cell infusion (CTI) in 109 patients from three clinical trials (ChiCTR-OPN-16008526, ChiCTR-OPC-16009113, ChiCTR-OPN-16009847). Based on the dynamic changes of interleukin (IL)-6 and ferritin, we proposed the "double peaks of IL-6" pattern as a feature of life-threatening infection during the first 30 days after CTI. Meanwhile, we screened candidate biomarkers from 70-biomarker panel to establish a prediction model for life-threatening infection. RESULTS In this study, 19 patients (17.4%) experienced a total of 19 infection events during the first 30 days after CAR T-cell infusion. Eleven patients (10.1%) had grade 4-5 infection, which were all bacterial infection and predominantly sepsis (N = 9). "Double peaks of IL-6" appeared in 9 out of 11 patients with life-threatening infection. The prediction model of three-cytokines (IL-8, IL-1β and interferon-γ) could predict life-threatening infection with high sensitivity (training: 100.0%; validation: 100.0%) and specificity (training: 97.6%; validation: 82.8%). On base of the aforementioned methods, we proposed a workflow for quick identification of life-threatening infection during CAR T-cell therapy. CONCLUSIONS In this study, we worked out two diagnostic methods for life-threatening infection during CAR T-cell therapy by analyzing inflammatory signatures, which contributed to reducing risks of infection-induced death.
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Affiliation(s)
- Hui Luo
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Na Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Liang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Xiaoxi Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Jin Jin
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Chunrei Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Di Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Bin Xu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Jinhuan Xu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Lijun Jiang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Jue Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Yang Cao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Yi Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Qian Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Xia Mao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Songya Liu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Liting Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China. .,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, 430030, Hubei, China.
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Abstract
PURPOSE OF REVIEW Invasive fungal disease (IFD) and cytomegalovirus (CMV) infections occur frequently, either concomitantly or sequentially in immune-compromised hosts. Although there is extensive knowledge of the risk factors for these infections as single entities, the inter-relationship between opportunistic fungii and CMV has not been comprehensively explored. RECENT FINDINGS Both solid organ and stem cell transplant recipients who develop CMV invasive organ disease are at an increased risk of developing IFD, particularly aspergillosis and Pneumocystis pneumonia (PCP). Moreover, CMV viremia and recipient CMV serostatus also increased the risk of both early and late-onset IFD. Treatment-related factors, such as ganciclovir-induced neutropenia and host genetic Toll-like receptor (TLR) polymorphisms are likely to be contributory. Less is known about the relationship between CMV and IFD outside transplantation, such as in patients with hematological cancers or other chronic immunosuppressive conditions. Finally, few studies report on the relationship between CMV-specific treatments or the viral/antigen kinetics and its influence on IFD management. SUMMARY CMV infection is associated with increased risk of IFD in posttransplant recipients because of a number of overlapping and virus-specific risk factors. Better understanding of how CMV virus, its related treatment, CMV-induced immunosuppression and host genetic factors impact on IFD is warranted.
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21
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Krishna BA, Wills MR, Sinclair JH. Advances in the treatment of cytomegalovirus. Br Med Bull 2019; 131:5-17. [PMID: 31580403 PMCID: PMC6821982 DOI: 10.1093/bmb/ldz031] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/02/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Human cytomegalovirus (HCMV) is a threat to immunologically weak patients. HCMV cannot yet be eliminated with a vaccine, despite recent advances. SOURCES OF DATA Sources of data are recently published research papers and reviews about HCMV treatments. AREAS OF AGREEMENT Current antivirals target the UL54 DNA polymerase and are limited by nephrotoxicity and viral resistance. Promisingly, letermovir targets the HCMV terminase complex and has been recently approved by the FDA and EMA. AREAS OF CONTROVERSY Should we screen newborns for HCMV, and use antivirals to treat sensorineural hearing loss after congenital HCMV infection? GROWING POINTS Growing points are developing drugs against latently infected cells. In addition to small molecule inhibitors, a chemokine-based fusion toxin protein, F49A-FTP, has shown promise in killing both lytically and latently infected cells. AREAS TIMELY FOR DEVELOPING RESEARCH We need to understand what immune responses are required to control HCMV, and how best to raise these immune responses with a vaccine.
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Affiliation(s)
- B A Krishna
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M R Wills
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - J H Sinclair
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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22
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Pande A, Dubberke ER. Cytomegalovirus Infections of the Stem Cell Transplant Recipient and Hematologic Malignancy Patient. Infect Dis Clin North Am 2019; 33:485-500. [DOI: 10.1016/j.idc.2019.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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23
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Johnson BH, Taylor A, Kim G, Drahos J, Yang J, Akbari M, Shah NN. Clinical Outcomes and Healthcare Resource Utilization for Gastrointestinal Acute Graft-versus-Host Disease after Allogeneic Transplantation for Hematologic Malignancy: A Retrospective US Administrative Claims Database Analysis. Biol Blood Marrow Transplant 2019; 25:834-841. [PMID: 30625389 DOI: 10.1016/j.bbmt.2018.12.839] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
Abstract
Graft-versus-host disease (GVHD) is the leading cause of nonrelapse mortality among patients who receive allogeneic hematopoietic cell transplantation (allo-HCT). In its acute form (aGVHD), GVHD involves the skin, liver, and gastrointestinal (GI) tract, with GI involvement most strongly associated with poor prognosis. This retrospective cohort study used US healthcare claims data for 2008 to 2015 to identify patients who developed GI aGVHD after allo-HCT performed as curative treatment for hematologic malignancy and compared them with patients who did not develop aGVHD in terms of outcomes related to survival, infections, healthcare resource utilization (HRU), and costs. Whereas the patients without aGVHD saw a 66% improvement in 1-year survival between 2009 and 2015, this effect was not observed in patients with GI aGVHD. Compared with patients without evidence of aGVHD, patients with GI aGVHD were 3.9-fold more likely to develop an infection in the year after allo-HCT. Similarly, patients who developed GI aGVHD were 4.3-fold more likely to have an inpatient admission after allo-HCT discharge, and such an admission cost on average 47% more than an admission for patients without aGVHD. Our findings confirm that GI involvement in aGVHD is associated with higher mortality, risk of infection, HRU, and cost compared with absence of aGVHD.
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Affiliation(s)
| | - Aliki Taylor
- Takeda Pharmaceuticals International, London, United Kingdom
| | - Gilwan Kim
- IBM Watson Health, Cambridge, Massachusetts
| | | | - Jiao Yang
- Takeda Pharmaceuticals International, Boston, Massachusetts
| | - Mona Akbari
- Takeda Pharmaceuticals International, Boston, Massachusetts
| | - Nirav N Shah
- Medical College of Wisconsin, Milwaukee, Wisconsin
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24
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Kao RL, Holtan SG. Host and Graft Factors Impacting Infection Risk in Hematopoietic Cell Transplantation. Infect Dis Clin North Am 2019; 33:311-329. [PMID: 30940461 DOI: 10.1016/j.idc.2019.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Infection contributes significantly to morbidity and mortality in hematopoietic cell transplantation. A complex interplay of host, graft, and technical factors contributes to infectious risk in the recipient. Host factors such as age, underlying disease, and comorbidities; central venous access; and the preparative regimen contribute to mucosal disruption, organ dysfunction, and immunodeficiency before hematopoietic cell transplantation. Graft factors, including donor histocompatibility, cell source, and graft components, along with immunosuppression and graft-versus-host disease, contribute to the speed of immune reconstitution. Evaluation of these factors, plus previous and posttransplant exposure to pathogens, is necessary to best assess an individual recipient's infection risk.
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Affiliation(s)
- Roy L Kao
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, 420 Delaware Street Southeast, MMC 480, Minneapolis, MN 55455, USA.
| | - Shernan G Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, 420 Delaware Street Southeast, MMC 480, Minneapolis, MN 55455, USA
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25
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Invasive Aspergillosis in Pediatric Leukemia Patients: Prevention and Treatment. J Fungi (Basel) 2019; 5:jof5010014. [PMID: 30754630 PMCID: PMC6463058 DOI: 10.3390/jof5010014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 12/16/2022] Open
Abstract
The purpose of this article is to review and update the strategies for prevention and treatment of invasive aspergillosis (IA) in pediatric patients with leukemia and in patients with hematopoietic stem cell transplantation. The major risk factors associated with IA will be described since their recognition constitutes the first step of prevention. The latter is further analyzed into chemoprophylaxis and non-pharmacologic approaches. Triazoles are the mainstay of anti-fungal prophylaxis while the other measures revolve around reducing exposure to mold spores. Three levels of treatment have been identified: (a) empiric, (b) pre-emptive, and (c) targeted treatment. Empiric is initiated in febrile neutropenic patients and uses mainly caspofungin and liposomal amphotericin B (LAMB). Pre-emptive is a diagnostic driven approach attempting to reduce unnecessary use of anti-fungals. Treatment targeted at proven or probable IA is age-dependent, with voriconazole and LAMB being the cornerstones in >2yrs and <2yrs age groups, respectively.
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26
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Invasive fungal disease is associated with chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplant: a single center, retrospective study. Infection 2019; 47:275-284. [PMID: 30734248 DOI: 10.1007/s15010-018-01265-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/29/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Invasive fungal disease (IFD) and graft-versus-host disease (GVHD) are major causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, the impacts of IFD on chronic GVHD remain unknown. METHODS We conducted a retrospective study of 510 patients with hematologic malignancy undergoing allo-HSCT to explore the effects of IFD on chronic GVHD. RESULTS The 2-year cumulative incidences of overall (limited and extensive) and extensive chronic GVHD post-transplantation were higher in patients with IFD compared with those without IFD (69.5% ± 4.2% versus 32.9% ± 2.4%, P < .001; 43.0% ± 5.2% versus 6.6% ± 1.4%, P < .001, respectively). Moreover, the patients with IFD had higher 5-year transplant-related mortality, lower 5-year overall survival and lower 5-year disease-free survival (29.8% ± 4.3% versus 9.8% ± 1.6%, P < .001; 50.5% ± 4.9% versus 71.3% ± 2.4%, P < .001 and 48.8% ± 4.7% versus 71.8% ± 2.3%, P < .001, respectively). Multivariable analyses demonstrated that IFD increased the risk of chronic GVHD. CONCLUSION Our results suggest that IFD significantly contributes to the development of chronic GVHD after allo-HSCT.
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27
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Safdar A, Pouch SM, Scully B. Infections in Allogeneic Stem Cell Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2018. [PMCID: PMC7121717 DOI: 10.1007/978-1-4939-9034-4_11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become a widely used modality of therapy for a variety of malignant and nonmalignant diseases. Despite advances in pharmacotherapy and transplantation techniques, infection remains one of the most severe and frequently encountered complications of allo-HSCT. This chapter will address the risk factors for development of infection following allo-HSCT, including those related to the host, the conditioning regimen, and the graft, as well as the timing of opportunistic infections after allo-HSCT. The most common bacterial, viral, fungal, and parasitic infections, as well as issues surrounding their diagnostics and treatment, will be discussed. Finally, this chapter will address vaccination and other preventative strategies to be utilized when caring for patients undergoing allo-HSCT.
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Affiliation(s)
- Amar Safdar
- grid.416992.10000 0001 2179 3554Clinical Associate Professor of Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX USA
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28
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Thanarajasingam G, Minasian LM, Baron F, Cavalli F, De Claro RA, Dueck AC, El-Galaly TC, Everest N, Geissler J, Gisselbrecht C, Gribben J, Horowitz M, Ivy SP, Jacobson CA, Keating A, Kluetz PG, Krauss A, Kwong YL, Little RF, Mahon FX, Matasar MJ, Mateos MV, McCullough K, Miller RS, Mohty M, Moreau P, Morton LM, Nagai S, Rule S, Sloan J, Sonneveld P, Thompson CA, Tzogani K, van Leeuwen FE, Velikova G, Villa D, Wingard JR, Wintrich S, Seymour JF, Habermann TM. Beyond maximum grade: modernising the assessment and reporting of adverse events in haematological malignancies. Lancet Haematol 2018; 5:e563-e598. [PMID: 29907552 PMCID: PMC6261436 DOI: 10.1016/s2352-3026(18)30051-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 02/06/2023]
Abstract
Tremendous progress in treatment and outcomes has been achieved across the whole range of haematological malignancies in the past two decades. Although cure rates for aggressive malignancies have increased, nowhere has progress been more impactful than in the management of typically incurable forms of haematological cancer. Population-based data have shown that 5-year survival for patients with chronic myelogenous and chronic lymphocytic leukaemia, indolent B-cell lymphomas, and multiple myeloma has improved markedly. This improvement is a result of substantial changes in disease management strategies in these malignancies. Several haematological malignancies are now chronic diseases that are treated with continuously administered therapies that have unique side-effects over time. In this Commission, an international panel of clinicians, clinical investigators, methodologists, regulators, and patient advocates representing a broad range of academic and clinical cancer expertise examine adverse events in haematological malignancies. The issues pertaining to assessment of adverse events examined here are relevant to a range of malignancies and have been, to date, underexplored in the context of haematology. The aim of this Commission is to improve toxicity assessment in clinical trials in haematological malignancies by critically examining the current process of adverse event assessment, highlighting the need to incorporate patient-reported outcomes, addressing issues unique to stem-cell transplantation and survivorship, appraising challenges in regulatory approval, and evaluating toxicity in real-world patients. We have identified a range of priority issues in these areas and defined potential solutions to challenges associated with adverse event assessment in the current treatment landscape of haematological malignancies.
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Affiliation(s)
| | - Lori M Minasian
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | - Frederic Baron
- Division of Haematology, University of Liege, Liege, Belgium
| | - Franco Cavalli
- Oncology Institute of Southern Switzerland, Bellinzona, Switzlerand
| | - R Angelo De Claro
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Amylou C Dueck
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | - Tarec C El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg Denmark
| | - Neil Everest
- Haematology Clinical Evaluation Unit, Therapeutic Goods Administration, Department of Health, Symondston, ACT, Australia
| | - Jan Geissler
- Leukaemia Patient Advocates Foundation, Bern, Switzerland
| | - Christian Gisselbrecht
- Haemato-Oncology Department, Hopital Saint-Louis, Paris Diderot University VII, Paris, France
| | - John Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, London, UK
| | - Mary Horowitz
- Division of Haematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - S Percy Ivy
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | - Caron A Jacobson
- Division of Haematologic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Armand Keating
- Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Paul G Kluetz
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Aviva Krauss
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Yok Lam Kwong
- Department of Haematology and Haematologic Oncology, University of Hong Kong, Hong Kong, China
| | - Richard F Little
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | | | - Matthew J Matasar
- Lymphoma and Adult BMT Services, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Robert S Miller
- CancerLinQ, American Society of Clinical Oncology, Alexandria, VA, USA
| | - Mohamad Mohty
- Haematology and Cellular Therapy Department, Saint-Antoine Hospital, University Pierre & Marie Curie, Paris, France
| | | | - Lindsay M Morton
- National Cancer Institute, National Institutes of Health, Department of Health & Human Services, Bethesda, MD, USA
| | - Sumimasa Nagai
- University of Tokyo, Tokyo, Japan; Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Simon Rule
- Plymouth University Medical School, Plymouth, UK
| | - Jeff Sloan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Pieter Sonneveld
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | | | | | - Galina Velikova
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Diego Villa
- Division of Medical Oncology, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada
| | - John R Wingard
- Division of Haematology & Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sophie Wintrich
- Myelodysplastic Syndrome (MDS) Alliance and MDS UK Patient Support Group, London, UK
| | - John F Seymour
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Royal Melbourne Hospital, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
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Unexpected High Incidence of Human Herpesvirus-6 Encephalitis after Naive T Cell-Depleted Graft of Haploidentical Stem Cell Transplantation in Pediatric Patients. Biol Blood Marrow Transplant 2018; 24:2316-2323. [PMID: 30031939 DOI: 10.1016/j.bbmt.2018.07.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/10/2018] [Indexed: 11/21/2022]
Abstract
The CD45RA T cell depletion (TCD) method has been used to deplete naive T cells, preventing graft-versus-host disease (GVHD) but preserving memory cells, providing immediate functional T cells with anti-infection, antileukemia, and antirejection effects. We describe a series of 25 consecutive high-risk patients with leukemia who received haploidentical hematopoietic stem cell transplantation (haplo-HSCT) with CD45RA TCD. Each patient received 2 cell products: 1 created by CD34 positive selection and the other through CD45RA depletion from the CD34 negative fraction by a CliniMACS device. CD45RA-depleted haplo-HSCT was well tolerated, with rapid engraftment and low risk of severe acute GVHD and chronic GVHD. Although this treatment achieved a good control of viral reactivations, such as cytomegalovirus and adenovirus, we observed an unexpectedly high rate of limbic encephalitis due to human herpesvirus-6 (HHV-6; 8 cases). Characteristically, the infection appeared early in almost all patients, just after the engraftment. Although no patient died from encephalitis, 1 patient showed neuropsychological sequelae, and another experienced secondary graft failure just after the HHV-6 reactivation.
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30
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Banfalvi G. Improved and adopted murine models to combat pulmonary aspergillosis. Appl Microbiol Biotechnol 2018; 102:6865-6875. [DOI: 10.1007/s00253-018-9161-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 12/20/2022]
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31
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El-Jawahri AR, Schaefer PW, El Khoury JB, Martinez-Lage M. Case 5-2018: A 63-Year-Old Man with Confusion after Stem-Cell Transplantation. N Engl J Med 2018; 378:659-669. [PMID: 29443669 DOI: 10.1056/nejmcpc1707556] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Areej R El-Jawahri
- From the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
| | - Pamela W Schaefer
- From the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
| | - Joseph B El Khoury
- From the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
| | - Maria Martinez-Lage
- From the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Massachusetts General Hospital, and the Departments of Medicine (A.R.E.-J., J.B.E.K.), Radiology (P.W.S.), and Pathology (M.M.-L.), Harvard Medical School - both in Boston
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32
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Virus infection facilitates the development of severe pneumonia in transplant patients with hematologic malignancies. Oncotarget 2018; 7:53930-53940. [PMID: 27340772 PMCID: PMC5288233 DOI: 10.18632/oncotarget.10182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 05/16/2016] [Indexed: 12/19/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is an effective therapy for patients with hematologic malignancies. Severe pneumonia is associated with high mortality rate in HSCT recipients. Viral co-infection indicates a poor prognosis of HSCT recipients. In this study, a total of 68 allogeneic HSCT recipients were included. Cytomegalovirus (CMV) and Respiratory syncytial virus (RSV) infection was assessed by testing peripheral blood and oropharynx swabs, respectively, collected in the first 180 days after transplantation. We analysed the correlation of CMV and RSV co-infection with severe pneumonia and mortality. The incidence of CMV and RSV co-infection was 26.5% (18/68). Severe pneumonia was diagnosed in 61% (11/18) cases with co-infection compared to only 10% (5/50) cases with mono-infection or no infection. The analysis of potential risk factors for severe pneumonia showed that CMV and RSV co-infection was significantly associated with severe pneumonia (p < 0.001). The 5 patients who died of severe pneumonia were all co-infected with CMV and RSV. In conclusion, CMV and RSV co-infection appears to be an important factor and facilitates the development of severe pneumonia in allogeneic HSCT patients with hematologic malignancies.
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33
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Epstein DJ, Seo SK, Brown JM, Papanicolaou GA. Echinocandin prophylaxis in patients undergoing haematopoietic cell transplantation and other treatments for haematological malignancies. J Antimicrob Chemother 2018; 73:i60-i72. [PMID: 29304213 PMCID: PMC7189969 DOI: 10.1093/jac/dkx450] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Antifungal prophylaxis is the standard of care for patients undergoing intensive chemotherapy for haematological malignancy or haematopoietic cell transplantation (HCT). Prophylaxis with azoles reduces invasive fungal infections and may reduce mortality. However, breakthrough infections still occur, and the use of azoles is sometimes complicated by pharmacokinetic variability, drug interactions, adverse events and other issues. Echinocandins are highly active against Candida species, including some organisms resistant to azoles, and have some clinical activity against Aspergillus species as well. Although currently approved echinocandins require daily intravenous administration, the drugs have a favourable safety profile and more predictable pharmacokinetics than mould-active azoles. Clinical data support the efficacy and safety of echinocandins for antifungal prophylaxis in haematology and HCT patients, though data are less robust than for azoles. Notably, sparse evidence exists supporting the use of echinocandins as antifungal prophylaxis for patients with significant graft-versus-host disease (GvHD) after HCT. Two drugs that target (1,3)-β-d-glucan are in development, including an oral glucan synthase inhibitor and an echinocandin with unique pharmacokinetics permitting subcutaneous and weekly administration. Echinocandins are a reasonable alternative to azoles and other agents for antifungal prophylaxis in patients undergoing intensive chemotherapy for haematological malignancy or those receiving HCT, excluding those with significant GvHD.
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Affiliation(s)
- David J Epstein
- Division of Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | - Susan K Seo
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Janice M Brown
- Division of Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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34
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Tandra A, Covut F, Cooper B, Creger R, Brister L, McQuigg B, Caimi P, Malek E, Tomlinson B, Lazarus HM, Otegbeye F, Kolk M, de Lima M, Metheny L. Low dose anti-thymocyte globulin reduces chronic graft-versus-host disease incidence rates after matched unrelated donor transplantation. Leuk Lymphoma 2017; 59:1644-1651. [PMID: 29199482 DOI: 10.1080/10428194.2017.1390234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Anti-thymocyte globulin (ATG) is often added to hematopoietic stem cell transplant conditioning regimens to prevent graft rejection and reduce graft-versus-host disease (GVHD). Doses used in retrospective and prospective clinical trials have ranged from 2.5 to 20 mg/kg with rates of grade II-IV acute GVHD and chronic GVHD up to 40 and 60%, respectively. We retrospectively compared outcomes in recipients of matched unrelated donor (MUD) grafts given low dose rabbit ATG IV 3 mg/kg (n = 52) versus recipients of matched related donor (MRD) grafts (n = 48) without ATG. One year cumulative incidence of chronic GVHD was 25.2% in the MUD group versus 33.3% in the MRD group (p = .5). One-year cumulative incidence of extensive chronic GVHD was 9.6% in the MUD group versus 26.6% in the MRD group (p = .042). Our analysis supports the use of low dose ATG in MUD transplantation as an effective therapy to prevent chronic GVHD.
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Affiliation(s)
- Anand Tandra
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Fahrettin Covut
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Brenda Cooper
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Richard Creger
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Lauren Brister
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Bernadette McQuigg
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Paolo Caimi
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Ehsan Malek
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Ben Tomlinson
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Hillard M Lazarus
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Folashade Otegbeye
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Merle Kolk
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Marcos de Lima
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
| | - Leland Metheny
- a Stem Cell Transplant Program , University Hospitals Cleveland Medical Center and Case Western Reserve University , Cleveland , OH , USA
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Affiliation(s)
- Margaret L Green
- University of Washington, 1959 NE Pacific Street, Box 359930, Seattle, WA 98195, USA; Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109, USA.
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Infectious complications of CD19-targeted chimeric antigen receptor-modified T-cell immunotherapy. Blood 2017; 131:121-130. [PMID: 29038338 DOI: 10.1182/blood-2017-07-793760] [Citation(s) in RCA: 396] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/08/2017] [Indexed: 12/11/2022] Open
Abstract
Lymphodepletion chemotherapy with CD19-targeted chimeric antigen receptor-modified T (CAR-T)-cell immunotherapy is a novel treatment for refractory or relapsed B-cell malignancies. Infectious complications of this approach have not been systematically studied. We evaluated infections occurring between days 0 to 90 in 133 patients treated with CD19 CAR-T cells in a phase 1/2 study. We used Poisson and Cox regression to evaluate pre- and posttreatment risk factors for infection, respectively. The cohort included patients with acute lymphoblastic leukemia (ALL; n = 47), chronic lymphocytic leukemia (n = 24), and non-Hodgkin lymphoma (n = 62). There were 43 infections in 30 of 133 patients (23%) within 28 days after CAR-T-cell infusion with an infection density of 1.19 infections for every 100 days at risk. There was a lower infection density of 0.67 between days 29 and 90 (P = .02). The first infection occurred a median of 6 days after CAR-T-cell infusion. Six patients (5%) developed invasive fungal infections and 5 patients (4%) had life-threatening or fatal infections. Patients with ALL, ≥4 prior antitumor regimens, and receipt of the highest CAR-T-cell dose (2 × 107 cells per kg) had a higher infection density within 28 days in an adjusted model of baseline characteristics. Cytokine release syndrome (CRS) severity was the only factor after CAR-T-cell infusion associated with infection in a multivariable analysis. The incidence of infections was comparable to observations from clinical trials of salvage chemoimmunotherapies in similar patients. This trial was registered at www.clinicaltrials.gov as #NCT01865617.
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37
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Multi-Sites Infection Caused by Klebsiella pneumoniae After Hemopoietic Stem Cell Transplantation. Jundishapur J Microbiol 2017. [DOI: 10.5812/jjm.12933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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38
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Gea-Banacloche J, Komanduri KV, Carpenter P, Paczesny S, Sarantopoulos S, Young JA, El Kassar N, Le RQ, Schultz KR, Griffith LM, Savani BN, Wingard JR. National Institutes of Health Hematopoietic Cell Transplantation Late Effects Initiative: The Immune Dysregulation and Pathobiology Working Group Report. Biol Blood Marrow Transplant 2017; 23:870-881. [PMID: 27751936 PMCID: PMC5392182 DOI: 10.1016/j.bbmt.2016.10.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/05/2016] [Indexed: 12/11/2022]
Abstract
Immune reconstitution after hematopoietic stem cell transplantation (HCT) beyond 1 year is not completely understood. Many transplant recipients who are free of graft-versus-host disease (GVHD) and not receiving any immunosuppression more than 1 year after transplantation seem to be able to mount appropriate immune responses to common pathogens and respond adequately to immunizations. However, 2 large registry studies over the last 2 decades seem to indicate that infection is a significant cause of late mortality in some patients, even in the absence of concomitant GVHD. Research on this topic is particularly challenging for several reasons. First, there are not enough long-term follow-up clinics able to measure even basic immune parameters late after HCT. Second, the correlation between laboratory measurements of immune function and infections is not well known. Third, accurate documentation of infectious episodes is notoriously difficult. Finally, it is unclear what measures can be implemented to improve the immune response in a clinically relevant way. A combination of long-term multicenter prospective studies that collect detailed infectious data and store samples as well as a national or multinational registry of clinically significant infections (eg, vaccine-preventable severe infections, opportunistic infections) could begin to address our knowledge gaps. Obtaining samples for laboratory evaluation of the immune system should be both calendar and eventdriven. Attention to detail and standardization of practices regarding prophylaxis, diagnosis, and definitions of infections would be of paramount importance to obtain clean reliable data. Laboratory studies should specifically address the neogenesis, maturation, and exhaustion of the adaptive immune system and, in particular, how these are influenced by persistent alloreactivity, inflammation, and viral infection. Ideally, some of these long-term prospective studies would collect information on long-term changes in the gut microbiome and their influence on immunity. Regarding enhancement of immune function, prospective measurement of the response to vaccines late after HCT in a variety of clinical settings should be undertaken to better understand the benefits as well as the limitations of immunizations. The role of intravenous immunoglobulin is still not well defined, and studies to address it should be encouraged.
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Affiliation(s)
- Juan Gea-Banacloche
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bethesda, Maryland.
| | - Krishna V Komanduri
- Sylvester Adult Stem Cell Transplant Program, University of Miami, Coral Gables, Florida
| | - Paul Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine Pediatrics, Seattle, Washington
| | - Sophie Paczesny
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Stefanie Sarantopoulos
- Division of Hematological Malignancies and Cellular Therapy, Duke University Department of Medicine and Duke Cancer Institute, Durham, North Carolina
| | - Jo-Anne Young
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Nahed El Kassar
- National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Robert Q Le
- Medical Officer, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Kirk R Schultz
- Professor of Pediatrics, UBC, Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital and Research Institute, Vancouver, Canada
| | - Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Bipin N Savani
- Long Term Transplant Clinic, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John R Wingard
- University of Florida Health Cancer Center, Gainesville, Florida; Bone Marrow Transplant Program, Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
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39
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Chan ST, Logan AC. The clinical impact of cytomegalovirus infection following allogeneic hematopoietic cell transplantation: Why the quest for meaningful prophylaxis still matters. Blood Rev 2017; 31:173-183. [DOI: 10.1016/j.blre.2017.01.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/16/2016] [Accepted: 01/31/2017] [Indexed: 11/28/2022]
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40
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Reprint of: Long-Term Survivorship after Hematopoietic Cell Transplantation: Roadmap for Research and Care. Biol Blood Marrow Transplant 2017; 23:S1-S9. [PMID: 28236836 DOI: 10.1016/j.bbmt.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/02/2016] [Indexed: 12/23/2022]
Abstract
The number of survivors after hematopoietic cell transplantation (HCT) is expected to dramatically increase over the next decade. Significant and unique challenges confront survivors for decades after their underlying indication (malignancy or marrow failure) has been cured by HCT. The National Institutes of Health (NIH) Late Effects Consensus Conference in June 2016 brought together international experts in the field to plan the next phase of survivorship efforts. Working groups laid out the roadmap for collaborative research and health care delivery. Potentially lethal late effects (cardiac/vascular, subsequent neoplasms, and infectious), patient-centered outcomes, health care delivery, and research methodology are highlighted here. Important recommendations from the NIH Consensus Conference provide fresh perspectives for the future. As HCT evolves into a safer and higher-volume procedure, this marks a time for concerted action to ensure that no survivor is left behind.
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41
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Battiwalla M, Tichelli A, Majhail NS. Long-Term Survivorship after Hematopoietic Cell Transplantation: Roadmap for Research and Care. Biol Blood Marrow Transplant 2017; 23:184-192. [PMID: 27818318 PMCID: PMC5237604 DOI: 10.1016/j.bbmt.2016.11.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022]
Abstract
The number of survivors after hematopoietic cell transplantation (HCT) is expected to dramatically increase over the next decade. Significant and unique challenges confront survivors for decades after their underlying indication (malignancy or marrow failure) has been cured by HCT. The National Institutes of Health (NIH) Late Effects Consensus Conference in June 2016 brought together international experts in the field to plan the next phase of survivorship efforts. Working groups laid out the roadmap for collaborative research and health care delivery. Potentially lethal late effects (cardiac/vascular, subsequent neoplasms, and infectious), patient-centered outcomes, health care delivery, and research methodology are highlighted here. Important recommendations from the NIH Consensus Conference provide fresh perspectives for the future. As HCT evolves into a safer and higher-volume procedure, this marks a time for concerted action to ensure that no survivor is left behind.
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Affiliation(s)
- Minoo Battiwalla
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland.
| | | | - Navneet S Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
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42
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Marr KA. Infections in Hematopoietic Stem Cell Transplant Recipients. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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43
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Abstract
Viral pneumonias in patients with hematologic malignancies and recipients of hematopoietic stem cell transplantation cause significant morbidity and mortality. Advances in diagnostic techniques have enabled rapid identification of respiratory viral pathogens from upper and lower respiratory tract samples. Lymphopenia, myeloablative and T-cell depleting chemotherapy, graft-versus-host disease, and other factors increase the risk of developing life-threatening viral pneumonia. Chest imaging is often nonspecific but may aid in diagnoses. Bronchoscopy with bronchoalveolar lavage is recommended in those at high risk for viral pneumonia who have new infiltrates on chest imaging.
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44
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Castillo N, García-Cadenas I, Barba P, Canals C, Díaz-Heredia C, Martino R, Ferrà C, Badell I, Elorza I, Sierra J, Valcárcel D, Querol S. Early and Long-Term Impaired T Lymphocyte Immune Reconstitution after Cord Blood Transplantation with Antithymocyte Globulin. Biol Blood Marrow Transplant 2016; 23:491-497. [PMID: 27888015 DOI: 10.1016/j.bbmt.2016.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/16/2016] [Indexed: 01/13/2023]
Abstract
Immune reconstitution is crucial to the success of allogeneic hematopoietic stem cell transplantation. Umbilical cord blood transplantation (UCBT) has been associated with delayed immune reconstitution. We characterized the kinetics and investigated the risk variables affecting recovery of the main lymphocyte subsets in 225 consecutive pediatric and adult patients (males, n = 126; median age, 15; range, .3 to 60; interquartile range, 4 to 35) who underwent myeloablative single UCBT between 2005 and 2015 for malignant and nonmalignant disorders. Low CD4+ and CD8+ T cell counts were observed up to 12 months after UCBT. In contrast, B and natural killer cells recovered rapidly early after transplantation. In a multivariate regression model, factors favoring CD4+ T cell recovery ≥ 200 cells/µL were lower dose antithymocyte globulin (ATG) (hazard ratio [HR], 3.93; 95% confidence interval [CI], 2.3 to 5.83; P = .001), negative recipient cytomegalovirus (CMV) serostatus (HR, 3.76; 95% CI, 1.9 to 5.74; P = .001), and younger age (HR, 2.61; 95% CI, 1.01 to 3.47; P = .03). Factors favoring CD8+ T cell recovery ≥ 200 cells/µL were lower dose ATG (HR, 3.03; 95% CI, 1.4 to 5.1; P = .03) and negative recipient CMV serostatus (HR, 1.9; 95% CI, 1.63 to 2.15; P = .01). Our results demonstrate the significant negative impact of ATG on lymphocyte recovery. A reduction of the dose or omission of ATG could improve immune reconstitution and perhaps reduce opportunistic infections after UCBT.
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Affiliation(s)
| | - Irene García-Cadenas
- Adult Hematology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Pere Barba
- Adult Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Cristina Díaz-Heredia
- Pediatric Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Rodrigo Martino
- Adult Hematology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Christelle Ferrà
- Adult Hematology Department, Institut Català d'Oncologia-Badalona, Barcelona, Spain
| | - Isabel Badell
- Pediatric Hematology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Izaskun Elorza
- Pediatric Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jorge Sierra
- Adult Hematology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - David Valcárcel
- Adult Hematology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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45
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Herrero-Sánchez MC, Rodríguez-Serrano C, Almeida J, San Segundo L, Inogés S, Santos-Briz Á, García-Briñón J, Corchete LA, San Miguel JF, Del Cañizo C, Blanco B. Targeting of PI3K/AKT/mTOR pathway to inhibit T cell activation and prevent graft-versus-host disease development. J Hematol Oncol 2016; 9:113. [PMID: 27765055 PMCID: PMC5072323 DOI: 10.1186/s13045-016-0343-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 10/08/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Graft-versus-host disease (GvHD) remains the major obstacle to successful allogeneic hematopoietic stem cell transplantation, despite of the immunosuppressive regimens administered to control T cell alloreactivity. PI3K/AKT/mTOR pathway is crucial in T cell activation and function and, therefore, represents an attractive therapeutic target to prevent GvHD development. Recently, numerous PI3K inhibitors have been developed for cancer therapy. However, few studies have explored their immunosuppressive effect. METHODS The effects of a selective PI3K inhibitor (BKM120) and a dual PI3K/mTOR inhibitor (BEZ235) on human T cell proliferation, expression of activation-related molecules, and phosphorylation of PI3K/AKT/mTOR pathway proteins were analyzed. Besides, the ability of BEZ235 to prevent GvHD development in mice was evaluated. RESULTS Simultaneous inhibition of PI3K and mTOR was efficient at lower concentrations than PI3K specific targeting. Importantly, BEZ235 prevented naïve T cell activation and induced tolerance of alloreactive T cells, while maintaining an adequate response against cytomegalovirus, more efficiently than BKM120. Finally, BEZ235 treatment significantly improved the survival and decreased the GvHD development in mice. CONCLUSIONS These results support the use of PI3K inhibitors to control T cell responses and show the potential utility of the dual PI3K/mTOR inhibitor BEZ235 in GvHD prophylaxis.
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Affiliation(s)
- Mª Carmen Herrero-Sánchez
- Servicio de Hematología, Hospital Universitario de Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | - Concepción Rodríguez-Serrano
- Servicio de Hematología, Hospital Universitario de Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | - Julia Almeida
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain.,Servicio de Citometría, Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | - Laura San Segundo
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | - Susana Inogés
- Laboratorio de Inmunoterapia, Clínica Universidad de Navarra, Avda. Pío XII 55, 31008, Pamplona, Spain
| | - Ángel Santos-Briz
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Departamento de Patología, Hospital Universitario de Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain
| | - Jesús García-Briñón
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Departamento de Biología Celular y Patología, Facultad de Medicina, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | - Luis Antonio Corchete
- Servicio de Hematología, Hospital Universitario de Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | - Jesús F San Miguel
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Avda. Pío XII 55, 31008, Pamplona, Spain
| | - Consuelo Del Cañizo
- Servicio de Hematología, Hospital Universitario de Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain
| | - Belén Blanco
- Servicio de Hematología, Hospital Universitario de Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain. .,Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente 58-182, 37007, Salamanca, Spain. .,Centro de Investigación del Cáncer, Universidad de Salamanca, Campus Miguel de Unamuno, 37007, Salamanca, Spain.
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46
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Pagano L, Busca A, Candoni A, Cattaneo C, Cesaro S, Fanci R, Nadali G, Potenza L, Russo D, Tumbarello M, Nosari A, Aversa F. Risk stratification for invasive fungal infections in patients with hematological malignancies: SEIFEM recommendations. Blood Rev 2016; 31:17-29. [PMID: 27682882 DOI: 10.1016/j.blre.2016.09.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/05/2016] [Accepted: 09/09/2016] [Indexed: 11/17/2022]
Abstract
Invasive fungal infections (IFIs) are an important cause of morbidity and mortality in immunocompromised patients. Patients with hematological malignancies undergoing conventional chemotherapy, autologous or allogeneic hematopoietic stem cell transplantation are considered at high risk, and Aspergillus spp. represents the most frequently isolated micro-organisms. In the last years, attention has also been focused on other rare molds (e.g., Zygomycetes, Fusarium spp.) responsible for devastating clinical manifestations. The extensive use of antifungal prophylaxis has reduced the infections from yeasts (e.g., candidemia) even though they are still associated with high mortality rates. This paper analyzes concurrent multiple predisposing factors that could favor the onset of fungal infections. Although neutropenia is common to almost all hematologic patients, other factors play a key role in specific patients, in particular in patients with AML or allogeneic HSCT recipients. Defining those patients at higher risk of IFIs may help to design the most appropriate diagnostic work-up and antifungal strategy.
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Affiliation(s)
- Livio Pagano
- Istituto di Ematologia, Università Cattolica S. Cuore, Roma, Italy.
| | - Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Anna Candoni
- Clinica Ematologica, Azienda Ospedaliero-Universitaria Santa Maria Misericordia, Udine, Italy
| | | | - Simone Cesaro
- Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rosa Fanci
- Unità Funzionale di Ematologia, Azienda Ospedaliero-Universitaria Careggi e Università di Firenze, Italy
| | - Gianpaolo Nadali
- Unità Operativa Complessa di Ematologia, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Leonardo Potenza
- UOC Ematologia, Dipartimento di Scienze Mediche e Chirurgiche Materno Infantili e dell'Adulto, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Domenico Russo
- Cattedra di Ematologia, Unità di Malattie del Sangue e Trapianto di Midollo Osseo, Dipartimento di Scienze Cliniche e Sperimentali, Università di Brescia e ASST Spedali Civili, Brescia, Italy
| | - Mario Tumbarello
- Istituto di Malattie Infettive, Università Cattolica S. Cuore, Roma, Italy
| | - Annamaria Nosari
- Divisione di Ematologia e Centro Trapianti Midollo, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Franco Aversa
- Hematology and BMT Unit, Department of Clinical and Experimental Medicine, University of Parma, Italy
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47
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Dropulic LK, Lederman HM. Overview of Infections in the Immunocompromised Host. Microbiol Spectr 2016; 4:10.1128/microbiolspec.DMIH2-0026-2016. [PMID: 27726779 PMCID: PMC8428766 DOI: 10.1128/microbiolspec.dmih2-0026-2016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 12/12/2022] Open
Abstract
Understanding the components of the immune system that contribute to host defense against infection is key to recognizing infections that are more likely to occur in an immunocompromised patient. In this review, we discuss the integrated system of physical barriers and of innate and adaptive immunity that contributes to host defense. Specific defects in the components of this system that predispose to particular infections are presented. This is followed by a review of primary immunodeficiency diseases and secondary immunodeficiencies, the latter of which develop because of a specific illness or condition or are treatment-related. The effects of treatment for neoplasia, autoimmune diseases, solid organ and stem cell transplants on host defenses are reviewed and associated with susceptibility to particular infections. In conclusion, an approach to laboratory screening for a suspected immunodeficiency is presented. Knowledge of which host defects predispose to specific infections allows clinicians to prevent, diagnose, and manage infections in their immunocompromised patients most effectively.
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Affiliation(s)
- Lesia K Dropulic
- The National Institutes of Health, National Institute of Allergy and Infectious Diseases, Division of Intramural Research, Bethesda, MD 20892
| | - Howard M Lederman
- Departments of Pediatrics, Medicine, and Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287
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48
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Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JAH, Bennett JE. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63:e1-e60. [PMID: 27365388 DOI: 10.1093/cid/ciw326] [Citation(s) in RCA: 1577] [Impact Index Per Article: 197.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Thomas F Patterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System
| | | | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom
| | - Jay A Fishman
- Massachusetts General Hospital and Harvard Medical School
| | | | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Vicki A Morrison
- Hennepin County Medical Center and University of Minnesota, Minneapolis
| | | | - Brahm H Segal
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, and Roswell Park Cancer Institute, New York
| | | | | | - Thomas J Walsh
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | | | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
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49
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Huang YT, Neofytos D, Foldi J, Kim SJ, Maloy M, Chung D, Castro-Malaspina H, Giralt SA, Papadopoulos E, Perales MA, Jakubowski AA, Papanicolaou GA. Cytomegalovirus Infection after CD34(+)-Selected Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1480-1486. [PMID: 27178374 DOI: 10.1016/j.bbmt.2016.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/03/2016] [Indexed: 11/16/2022]
Abstract
The effectiveness of preemptive treatment (PET) for cytomegalovirus (CMV) in recipients of ex vivo T cell-depleted (TCD) hematopoietic cell transplantation (HCT) by CD34(+) selection is not well defined. We analyzed 213 adults who received TCD-HCT at our institution from June 2010 through May 2014. Patients were monitored by a CMV quantitative PCR assay if recipient (R) or donor (D) were CMV seropositive. CMV viremia occurred early (median, 27 days after HCT) in 91 of 213 (42.7%) patients for a 180-day cumulative incidence of 84.5%, 61.8%, and 0 for R+/D+, R+/D-, and R-/D+ patients, respectively. CMV disease occurred in 5% of patients. In Cox regression analysis, R+/D+ status was associated with increased risk for CMV viremia compared with R+/D- (hazard ratio [HR], 1.79, 95% confidence interval [CI], 1.16 to 2.76, P = .01), whereas matched unrelated donor allograft was associated with decreased risk (HR, .62; 95% CI, .39 to .97, P = .04). Of 91 patients with CMV viremia, 52 (57%) had persistent viremia (>28 days duration). Time lag from detection of CMV viremia to PET was associated with incremental risk for persistent viremia (HR, 1.09; 95% CI, 1.01 to 1.18; P = .03). Overall, 166 of 213 (77.9%) patients were alive 1 year after HCT, with no difference between patients with and without CMV viremia or among the different CMV serostatus pairs (P = not significant). CMV viremia occurred in 70% of R + TCD-HCT. Delay in PET initiation was associated with persistent viremia. With PET, CMV R/D serostatus did not adversely impact survival in TCD-HCT on 1-year survival in the present cohort.
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Affiliation(s)
- Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dionysios Neofytos
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Julia Foldi
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dick Chung
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Esperanza Papadopoulos
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann A Jakubowski
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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50
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Herrero-Sánchez MC, Rodríguez-Serrano C, Almeida J, San-Segundo L, Inogés S, Santos-Briz Á, García-Briñón J, SanMiguel JF, Del Cañizo C, Blanco B. Effect of mTORC1/mTORC2 inhibition on T cell function: potential role in graft-versus-host disease control. Br J Haematol 2016; 173:754-68. [PMID: 26914848 DOI: 10.1111/bjh.13984] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/21/2015] [Indexed: 12/17/2022]
Abstract
The mechanistic target of rapamycin (mTOR) pathway is crucial for the activation and function of T cells, which play an essential role in the development of graft-versus-host disease (GvHD). Despite its partial ability to block mTOR pathway, the mTORC1 inhibitor rapamycin has shown encouraging results in the control of GvHD. Therefore, we considered that simultaneous targeting of both mTORC1 and mTORC2 complexes could exert a more potent inhibition of T cell activation and, thus, could have utility in GvHD control. To assess this assumption, we have used the dual mTORC1/mTORC2 inhibitors CC214-1 and CC214-2. In vitro studies confirmed the superior ability of CC214-1 versus rapamycin to block mTORC1 and mTORC2 activity and to reduce T cell proliferation. Both drugs induced a similar decrease in Th1/Th2 cytokine secretion, but CC214-1 was more efficient in inhibiting naïve T cell activation and the expression of T-cell activation markers. In addition, CC214-1 induced specific tolerance against alloantigens, while preserving anti-cytomegalovirus response. Finally, in a mouse model of GvHD, the administration of CC214-2 significantly improved mice survival and decreased GvHD-induced damages. In conclusion, the current study shows, for the first time, the immunosuppressive ability of CC214-1 on T lymphocytes and illustrates the role of CC214-2 in the allogeneic transplantation setting as a possible GvHD prophylaxis agent.
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Affiliation(s)
- Ma Carmen Herrero-Sánchez
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Salamanca, Spain
| | - Concepción Rodríguez-Serrano
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Salamanca, Spain
| | - Julia Almeida
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Servicio de Citometría, Centro de Investigación del Cáncer, Universidad de Salamanca, Salamanca, Spain
| | - Laura San-Segundo
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Salamanca, Spain
| | - Susana Inogés
- Laboratorio de Inmunoterapia, Clínica Universidad de Navarra, Pamplona, Spain
| | - Ángel Santos-Briz
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Departamento de Patología, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Jesús García-Briñón
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Departamento de Biología Celular y Patología, Facultad de Medicina, Salamanca, Spain
| | - Jesús F SanMiguel
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Consuelo Del Cañizo
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.,Centro de Investigación del Cáncer, Universidad de Salamanca, Salamanca, Spain
| | - Belén Blanco
- Servicio de Hematología, Hospital Universitario de Salamanca, Salamanca, Spain.,Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
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